Healthcare Provider Details

I. General information

NPI: 1972239655
Provider Name (Legal Business Name): HEATHER ROSE CHARLIE NCPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 HUTTON AVE
FARMINGTON NM
87402-7601
US

IV. Provider business mailing address

1305 HUTTON AVE
FARMINGTON NM
87402-7601
US

V. Phone/Fax

Practice location:
  • Phone: 505-330-6953
  • Fax:
Mailing address:
  • Phone: 505-330-6953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: